Brief Report

Thalamic Tumor Presenting as MajorDepression and Headache

Robert Jay Claire, M.D.

We re port th e case of a 39 yea r old male who pr esen ted with Maj or Depression,headach e, a nd apathy. Within six weeks of his initial presen tat ion th e patient diedfrom a "Central H erniation Syndrome" afte r biopsy of a left th ala mic lesion. Thesta tist ics of medi cal problem s pr esenting as psychi atric disorder s as well as recentlit erature on person al ity changes associa ted with th al a mic infi lt ration a re reviewed.

It is recogni zed th a t fro m 33-80% of inpatient psych ia tric pa tien ts hav e concur­re n t med ical disease. A large pr oportion of th ese a re unrecogni zed pri or to psych iat ­ric hospitali zation (I ) . In 1983, Martin clearly sta te d th at " psychia t ric sym pto ms areofte n th e ea rl ies t and occa sion ally th e only sympto ms of intracr anial tu mor." Mart inalso rep orted that slow growing tumors were ass ocia te d with depression a nd per son ­ality cha ng es. Primary tumors of th e th alamus were describ ed by Smyth a nd Sternover fifty yea rs ago when th ey described th at th ese pa ti en ts had a flat a ffect ,decr eased verbal ou tput and apathy (3) .

CASE REPORT

Mr. A was a thirty nin e year old white male, who pr esent ed a t a Vet eransOutreach Center with feelin gs of aba ndo nment, hopelessn ess, helpl essness a ndworthless ness. He had a four week hist ory of depressed mood man ifested by hyperson­mo lence (slee ping up to twenty hours a day), loss of interest in personal hygien e, anddi fficulty conce ntra t ing . Mr. A could not follow spo rting events on television for moreth an ten minutes. Mr. A had a well organized plan for suicide . He planned to waitunti l his wife graduated from nu rsing school, a nd whil e she was visiting her pa rentswith th eir child re n, he was going to shoo t himself in th e head.

At th e time of this initial pr esentation he com pla ined of global headaches,diplopi a , blurry vision, a nd vertigo. Two weeks before his pr esen ta tion to us, he wassee n at a Health Maint en an ce Organization where he was diagnosed as havinga nxie ty and sta r te d on a lprazola m.

Mr. A's onl y other contac t with psychi atry was one and one half years before thi spr esentat ion. He compla ined of being impulsive a nd irritable. Mr. A was felt to haveP.T.S.D. a nd a possib le impulse control disorder. He elec te d not to return for furth erpsychiatric eva lua tion a nd treatment a t that time.

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THALAMIC TUMOR PRESENTI NG AS MAJOR DEPRESSION AND HEADACHE

Mental S tatus Exam

55

Mr. A pr esented as a thirty nin e yea r old obese male who made poor eye contact.His spee ch was noted to be slightly pressured and tangential , but goal direct ed . Mr.A's mood was depressed and his affect was flat. His th ou ght processes includedconstan t ruminations about "bein g st ro ng minded " (which he used intercha ngeablywith st rong will ed ). There were some clem ent s of both th ough t broad casting a ndth ou ght blocking.

Mr. A demon strated some mild cog nit ive impairmen t, a nd he also gav e up eas ilyon all tasks. He insight was felt to be impaired.

Clini cal Course

Mr. A was adm itted to an inpatient psychi atric unit with d iagnosis of AtypicalMajor Depression and a recommendation for evalua tion for possibl e brain mass .While an inpatien t he was not ed to be impulsive and irrit abl e, with sui cid al ideation,hypersomnalen ce, fla t affect, ten pound weight loss a nd cognitive impairment.

During his hospitali zation Mr. A was sta r ted on im ipramine and titrated to adose of 125 mg. a t bedtime. There was a modera te clinica l respon se to th e medicationwith Mr. A sleeping less, being mor e ene rge t ic a nd less apa thetic. No serum levelswere obtai ne d and th e inpatient staff fail ed to orde r neu ro imaging studies. Exceptfor th e mental sta tus abnormalit ies not ed here no gross neurologica l findings werenot ed .

Aft er discharge Mr. A was see n in th e outpa tie n t clinic with some improvem entin his depressiv e symptoms, but he complained of intermittent head ach e, diploplia,a nd vertigo. A CAT sca n of th e br ain was orde re d, however before it could beperformed Mr. A pr esented to th e urgent ca re area with complaint of severehead ach e, depression and a pa thy. A lu mb ar pun ct ure was perform ed revealing:glucose 59, protein 90 (nl 15-45), 2 RBC, 14 WBC , 4 Polys, 59 Lymph, a nd 37Histiocyt es. The patient was admitted to th e Ne uro logy Se rvice.

The physical exa m was unrem arkabl e. A rep ea t lumbar puncture yielde d aglucose of 58 a nd a prot ein of 11 2. The CAT sca n of the br ai n revealed a leftsubcort ica l enhancing lesion abutt ing the th al a mic region. An MRI of the brain withga do linium enhance ment demonstrat ed a subco rt ica l mass ex te nd ing into the th ala­mus a nd left lat eral vent ricle . Ne uropsycho logical evalua tion was compatib le withpsych om ot or slowing, va riable a tten tion spa n, defecit s with abst ract reasoning, allconsis te n t with a subcortical lesion.

Mr. A was transferred to th e Ne urosurgica l Service where stereo tacti c biopsywas performed . The pathology spec ime n dem on strated gliobas toma multiforme.Postoperatively th e patient was even mor e drowsy a nd lethargic tha n he had beenpr eop eratively. Wh en left alon e Mr. A would immediately dose off. He req uired ex trast imula t ion to maintain wa kefulness . Wh en awa ke Mr. A would be oriented to threesphe res a nd was able to com prehe nd wha t was happeni ng to him. The nursing sta ffnoted a decr ease in verba l out put. Mr. A went on to develop expressive aphasia,

56 J EFFERSON J O URNAL OF PSYCHIATRY

neolo gism s, a nd pa raphrasia. H e had fr ank visu al field defect s and right hom on y­mous hemian op sia . A right hemian esthesia was a lso pr esent. He had clear optic d iscborders on fundoscopy a nd a decr ease in veno us pul sation.

Mr. A' s det eri oration was a t tr ibute d to post op erative ede ma, as well as bleedingfrom th e biopsy sit e. A brain CAT scan was done postoperatively, which revealedblood in th e op erative site and swelling in th e area of th e tumor bed. A slighten large me nt of th e ventricles was also obse rve d. H e was aggress ively treated forcerebral ede ma, with mo de ra te improvement. T reatment options wer e discu ssedwit h Mr. A and his fa mily, including VP shun t, radi at ion to th e tumor a nd /orresection of th e tumor. The patient a nd his fam ily opte d for no further intervention .Mr. A d ied of central herniation six wee ks after his in it ial presentation.

DISCUSSIO N

Gutmann et al recently report ed a case of " Pe rso na lity cha ng es associa ted withthalamic infiltration ," involvin g a twenty seven year old fe male pr esent ing withperson ality cha nges, soc ia l wit hdrawal, blunted a ffect, diminished verbal output ,brad ykin esia, and difficulty writing. U nlike Mr. A this pa tien t had bilateral exo pt ha l­mu s "with an inability to bury her scle rae on ex t remes of latera l gaze, a tran sversesmile with normal facial mot or fun cti on, r igh t handed clumsiness and right side dspatial neglect." There we re no othe r neu rol ogical ab no rmalit ies with th e exce pt ionof me ntal status cha nges. Gutmann's pa tie n t was t rea ted aggressively with dexameth-

. asone a nd pa rtial br ain ir radi ation (4) . At th e time of th e a rt icle, Gutmann's patienthad survived for 20 months.

As early as 1951 Bleul er rep orted th at in six hundred docu mented cases of br aintumor seve n ty percent were retrospectively not ed to have some deg ree of psychopa­th ology (4) . Galas ko e t al reported depression or apa t hy occu rr ing ea rly in the courseof seve n teen individual s wit h br ain tumors (5).

Lish man underscores th at som no le nce a nd hypersomnia are frequent withd iencep hali c tumors stati ng th at "T he hypersom nia d ue to a di en cephalic lesion isessent ia lly a n excess of normal slee p an d when roused t he patient awakens normallyand fully" (6) .

Our purpose in wr it ing this paper is to un derscore th e im port a nce of th oroughneu rological exam a nd neu ro-i magin g st ud ies in ad ults of for ty or older who have a ninitial episode of major psychi atric disorder marked by a pat hy, hypersom nolence,change in a ffect ive sta te, cog nit ive impairment , hallucin at ion or delus ions (6) . Werealize th at in th ese days of cos t containme nt our recommendation is con troversial,but eve n at a fifteen percent occurrence ra te the sav ing of lives and doll ars aresubs tan tial.

ACKJ"lOWLEDGEME ITS

The opinions ex pressed in this a r ticle a re sole ly t hose of th e author a nd sho uldnot be cons t rue d as th ose of th e U nive rs ity of California a t Davis or th e Departmentof Vet erans Affairs.

THALAMI C TUMOR PRESENTING AS MAJOR DEPRESSIO N AND HEADACH E 57

The a ut hor would like to thank Deborah S. Claire, R.N. , B.S.N., for administra­tive ass ista nce and Mark E. Servi s, M.D ., for ed ito ria l ass ista nce.

REFERE NCES

I. Spait e, Daniel W and Smith, Roger A: Psych ia tri c Pr esentation of Ment al IIIness. j ourn al ofEm ergen cy Medi cin e 1987; 5:367-373

2. Martin, Mauricej: A Bri ef Review of Organic Diseases Masquerading as Functional Illn ess.H ospital and Community Psychi atry 1983; 34(4):328-332

3. Sm yth GE, and St ern K: Tumors of th e Thalrnus-A C linicoPa tho log ica l Study, Brain 1938;6 1:339-74

4. Gutmann, David H, Grossm an, Robert I a nd Mollman, j oan E: Per sonal ity Ch angesAssociated with Thalamic In filtration :journal of Ne uro -O nco logy 1990; 8:263-267

5. Galasko, Dou glas, Kwo-Oh-Yuen PF a nd Thai , Leon : Intracr an ial Mass Les ions Associat edWith Late Onset Psychosis and Dep ression: Psychi atric C linics of No rt h America 1988;1:151-163

6. Lishman, Organic Psychi atry, Second Edition , pp 187-1 99